Madrid's I+D+i Model and Urban Health Research

El Modelo de I+D+i para Madrid
6 de Junio, Asamblea Madrid
Ciudades más saludables, más felices:
Desigualdades y Ciencia Ciudadana
Manuel Franco MD, PhD
Universidades Alcalá y Johns Hopkins

http://hhhproject.eu
I+D+I en Salud Urbana
1. En 2050: 66% de la población vivirá en ciudades.
2. Reto de la cronicidad y sus factores de riesgo en la ciudad.
3. Factores importantes como la pobreza, el desempleo y las
condiciones de trabajo muy patentes en la ciudad.
4. Desigualdades socioenómicas en nuestras ciudades.
Segregación. Desigualdades en Salud.
5. Ciudad, municipio, barrio como oportunidad para realizar
mejoras estructurales que mejoren la salud de millones.1
6. Investigación en Salud Urbana mediante nuevos datos,
nuevas metodologías, nuevos equipos interdisciplinares.
7. Ciencia Cudadana: Generar evidencia y actuar
(1) Franco, Bilal and Diez-Roux, J Epidemiol Comm Health 2015

Ciudades más saludables
Ciudadanos más felices
Life expectancy in high income
neighborhood: 85 years
Life expectancy in low income
Baltimore life expectancy gap
by neighbohoods: 18 years

Healthier cities, more equal cities
Franco, Bilal and Cooper, May 4th 2015
Como en el caso de Baltimore, es de radical importancia
conocer los procesos que nos han llevado a la situación actual.
La conjunción de políticas públicas desacertadas deriva en
ciudades en las que conviven dos realidades muy distintas,
creando barrios en los que se perpetúan el ciclo de pobreza, la
falta de oportunidades y futuro para los jóvenes, y la mala
salud de sus residentes.
¿Tenemos la voluntad para crear ciudades más justas, más
saludables, más libres y unidas y finalmente más felices?

New York City
San Francisco
Dallas
Detroit
7075808590
ExpectedAgeatDeathfor40YearOldsinYears
0 5
$30k
10
$60k
15
$101k
20
$683k
Race-Adjusted Expected Age at Death vs. Household Income
for Men in Selected Major Cities
Income and life expectancy in the US. Chetty, JAMA 2016

Mejorar la ciudad
Mejorar nuestra salud
And now we
come back to
study Madrid

Life expectancy in high income
Life expectancy in low income
Madrid life expectancy gap
by neighbohoods: 7 years
Ciudades más saludables,
más igualitarias

Social and Physical Urban
Environment and CV Health:
The Much Needed
Population Approach
Manuel Franco MD, PhD
For the HHH investigators

ERC Starting Grants
FUNDING 1.5 million € for 5 years
OBJECTIVE To encourage independent careers of excellent
investigators providing enough support in the critical
moment (starting to develop their own team).
ELEGIBILITY PI must have a PhD degree in the last 2 to 7 years.
Available to non-EU researchers.
REQUISITES At least one relevant publication without his/her
thesis advisor
At least 50% effort
PROFILE High potential, project with potential social
Impact in Europe.

Marco conceptual HHH
Barrios Cardio Saludables

To study the impact of the
social and physical environment in terms of
tobacco, alcohol, food and physical activity
on residents cardiovascular health
Heart Healthy Hoods
Overall Objectives

To provide scientific evidence to the general
population, researchers and policy makers to
intervene at the population level to prevent the
first cause of death in Europe
HHH overarching objective:
Policy and research implications

Photography
Knowledge
Dissemination
Citizen Science
Epidemiology
Health Sociology
University of Salamanca
Johns Hopkins School of Public Health
Geography
University of Alcalá
London School of Hygiene and
Tropical Medicine
Interdisciplinary team
PI: Social Epidemiology
University of Alcalá
Johns Hopkins School of Public Health

HHH Team September 2014
Kick off Meeting, 25 people

Mejorar la ciudad
21 Districts
128 Neighborhoods
2412 Census Units
3,2 Mill. Residents
Access to the
Integrated Primary
Care Health System
Database
1,4 million residents
40-75 ys. old

HHH Study Design
Baseline Visit
Cohort
Study
1st Database
Mining
Whole
Population
Study
4 year
follow up
2,500 participants Final Visit
Final Database
Mining
1,4 million people
Environment
Tobacco
Alcohol
Food
Physical Activity
1st Assessment 2nd AssessmentNeighborhoods
Multilevel Association
Analysis

Heart Healthy Hoods
13th International Conference of Urban Health
(ICUH) San Francisco April 2016

Methods (quantitative)
• Cardiovascular Disease:
– Whole population (>99%) EHR through universal health system.
– Validated (1) data on physician-diagnosed: diabetes, hypertension,
dyslipidemia, smoking and obesity.
• Urban environment
– Food: location and type of food stores and food services, directly
measured healthy food availability (brief NEMS-S)
– Physical activity: SPACES audit tool for walkability and bikeability,
SOPARC audit tool for open spaces.
– Alcohol and tobacco: location and type of retailers
References: (1) de Burgos Lunar et al, BMC Med Res Methodol, 2013.

Methods (qualitative)
• 11 semi-structured interviews with key informants:
4 long-term residents, 2 recent immigrants, 1 teacher,
1 community activist, 1 health care provider, 1 public
health officer, 1 local food store owner
• Questions on health and the environment, focusing
on sociodemographics, food, alcohol, tobacco and
physical activity.
• Analysis by triangulation incorporating an
interpretative phenomenological analysis.

Methods (integration)
• Geographic Information Systems
– Directly collected data + Secondary administrative data
– Joined to street sections by relational union or overlaid as
administrative boundaries/blocks.
• Mixed Methods Approach: merging approach
– Provides insights on quantitative findings
• Quantitative -> qualitative
– Guides future quantitative data collection (formative)
• Qualitative -> quantitative.

Exploratory Study Sociodemographic Profile
Primary Health Care Records
• Total Pilot Area Population: 15,751
• Population in the Primary Care Health System Geocoded to
census section level: 14,857 (95%)
– Possibility of obtaining data for 2 million people
• Median Age: 44 (Range: 0 to 106)
– 49% Above 45 years (CVD Health Target Group)
• Sex: 55% Women (65% in >75 years)
• Primary Care Health Centers: 98% in 3 centers
• Education: 50% > primary education
• Immigration: 19% foreign-born

• Population 45-106 ys. old: 7,252
• Sex: 59% Women
• Diabetes Prevalence: 12%
• Diabetes Control (HbA1c<7): 63%
• Hypertension Prevalence: 34%
• Obesity (BMI >30): 20%
• Dyslipidemia, all types: 32%
Exploratory Study Cardiovascular Profile
Primary Health Care Records

Results
Alcohol
(Restaurants and Liquor Stores)
Food Services
(Bars, Restaurants and Fast Food)
Tobacco
(Vending Machines & Stores)

Physical Activity Results
Pedro Gullón et al. September 2015 Journal of Urban Health,

Pilot Qualitative Study
Emergent categories
The role of immigration in shaping behavior patterns related
to the use of open spaces "... In the past other people would go
there [park], but now the Romanians are there..." (men, < 65 years )
Franco M, Gullon P, Carreño V. Studying city life, improving population health. Int J Epidemiol 2015

Emergent categories
The current economic crisis shaping the neighbor’s
behaviors "... Nowadays there are a lot of grandparents taking care of the
family…. Many unemployed descendants. So there is little time for healthy
habits like exercise... " (health care provider, woman)

Emergent categories
The role of social networks shaping health behavior patterns
in residents "I'm happy with people in my neighborhood. Since my
husband died, ... adults and kids alike, boys like my sons, 50 years-old,
[have told me] ‘hey, I work on this, if I can help you... I will help you with
stuff if you ask me’ " (woman, > 65 years)

Citizen
Science

General public engagement in scientific activities
Citizens actively contribute to science with their intellectual effort.
Volunteers acquire new learning and skills, and deeper understanding of
the scientific work in an appealing way.
As a result of this open, networked and trans-
disciplinary scenario, Society-Science-Policy
interactions are improved leading to a more
democratic research based on evidence-informed
decision making.
Citizen Science

Julia Díez, Paloma Conde, María Sandín, María Urtasun,
Remedios López, Joel Gittelsohn and Manuel Franco
Understanding community food
environment through Photovoice:
a participatory action research
project in Madrid
PhotoVoice is a project co-funded by

What is Photovoice?
• Innovative participatory-action research method
• It enables people to identify, capture, and reflect their
community´s strengths and concerns through photography
• Relevant scientific data for urban health
• Informs policy makers to promote health-related public policies

Setting Two neighborhoods of a
low-income area in Madrid (Spain).
Participants
- 24 residents (31-72 years old).
- A group of women and another
one of men per neighborhood.
Procedure
- A total of 163 pictures of their
local food environment
- Groups met at least for 5 sessions
two months
Photovoice Food Environment:
Methods

Participants´Analysis
- One best photograph
- Photographs discussed critically
individually and in groups
- 31 emerging themes for the 4 groups

31 themes finally merged into 5 main themes:
1. Eating in moderation
2. Cultural diversity
3. Food retailers
4. Socialization
5. Economic crisis and poverty
Results

Theme 1: Eating in moderation

Theme 2: Cultural diversity

Theme 3: Food retailers

Theme 4: Socialization

Theme 5: Economic crisis
and poverty

Research translation process
Participants and co-facilitators met twice to translate these
findings into policy recommendations aiming to improve the
local food environment.
Paper in progress, Maria Urtasun

Research translation process
11 food environment recommendations selected and ranked
Determinants of diet Recommendations (ranking)
Macro level determinants
of diet
- Offering local leisure time activities to avoid unhealthier
options as snacking and drinking alcohol and sodas (1)
- Improving nutrition labels (7)
- Promoting healthy social networks for older people (10)
- Giving street vendors legal status (11)
Organizational food
environment
- Improving food banks management (2)
- Reducing food waste (6)
- Healthier alternatives to workplace vending machines (8)
- Importance of food education in schools (9)
Community food
environment and
Consumer food
environment
- Reactivating traditional market and small retailers (3)
- Improving food hygiene conditions (4)
- Promoting the availability of organic and foods for people
with special needs (e.g. diabetes and celiac disease) (5)
Paper in progress, Maria Urtasun

Reunión de Ciencia Ciudadana
Alimentación
Ciudadanía Investigadores
Decisores
políticos
Concejal de distrito
Villaverde
Concejal de salud de
Madrid
Madrid Salud

Disseminating results and
reaching policy makers
Citizen Science Meeting Photography exhibit
• Residents participated in dissemination strategies: Photobook,
Videos, Scientific and cultural meetings, Media collaboration
• https://hhhproject.eu/photovoice/photovoice-publications/
• Participants co-analyze their data and coauthor papers
• Participants presented policy makers their results twice

CENTROCENTRO Cibeles
Madrid, April 13th – September 11th
https://hhhproject.eu/photovoice/photovoice-publications/

Mejorar la ciudad,

Madrid's I+D+i Model and Urban Health Research

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